| (a) Participation requirements. To participate in the
Texas Medicaid Program, a federally qualified health center (FQHC)
must:
(1) be receiving a grant under the Public Health Service
Act §§329, 330, or 340, or be designated by the secretary
of the Department of Health and Human Services as meeting the requirements
to be receiving such a grant;
(2) comply with all federal, state, and local laws
and regulations applicable to the services provided;
(3) be enrolled and approved for participation in the
Texas Medicaid Program;
(4) sign a written provider agreement with the Health
and Human Services Commission (HHSC) or its designee;
(5) comply with the terms of the provider agreement
and all requirements of the Texas Medicaid Program, including regulations,
rules, handbooks, standards, and guidelines published by HHSC; and
(6) bill for covered services in the manner and format
prescribed by HHSC.
(b) Affiliation agreements. Notwithstanding any other
provision, HHSC will not reimburse an FQHC for services performed
on behalf of the FQHC by a health-care provider under an affiliation
agreement with the FQHC unless the FQHC has submitted to HHSC an attestation
justifying the affiliation as required by paragraphs (3) and (4) of
this subsection and HHSC has deemed the affiliation justified.
(1) For purposes of this subsection, the term "affiliation
agreement" means an agreement that establishes a relationship between
an FQHC and a health-care provider ("affiliate") under which the affiliate
agrees to provide health-care services within the FQHC's scope of
services on behalf of the FQHC and to be reimbursed by the FQHC for
such services. The term does not include an employment agreement or
an agreement formalizing an arrangement in which an individual physician
either temporarily substitutes for a member of the FQHC's staff of
physicians or temporarily fills a vacancy in the FQHC's staff of physicians.
(2) For purposes of this subsection, the term "health-care
provider" means a physician, physician assistant, advanced practice
registered nurse (except certified registered nurse anesthetist),
visiting nurse, a qualified clinical psychologist, clinical social
worker, other health professional for mental health services, dentist,
dental hygienist, or an optometrist.
(3) The FQHC must justify the need for the affiliate
to perform services on the FQHC's behalf because the affiliation increases
access to care, expands the types of services offered by the FQHC,
or costs less than the employment of a physician.
(4) The FQHC must submit to HHSC an attestation, signed
by an individual with authority to sign documents on the FQHC's behalf,
explaining the need for the affiliation. The attestation must answer
and must explain the answers to the following questions:
(A) Does the affiliation governed by the agreement
increase access to care?
(B) Does the affiliation governed by the agreement:
(i) add services to the FQHC's scope of services; or
(ii) enable the FQHC to maintain access to care or
the services currently within the FQHC's scope of services?
(C) Would a health-care provider employed by the FQHC
be less expensive than the affiliation governed by the agreement?
(5) Once HHSC receives an attestation, it has 30 business
days to review the attestation and determine that the affiliation
is justified. If the FQHC does not receive information to the contrary
from HHSC within 35 business days after HHSC receives the attestation,
the affiliation is deemed justified.
(6) The FQHC may submit claims to HHSC for services
provided by the affiliate whose attestation is under review, but HHSC
will not pay the claims until HHSC deems the affiliation to be justified.
|
| Source Note: The provisions of this §354.1322 adopted to be effective August 1, 1990, 15 TexReg 4120; transferred effective September 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561; amended to be effective October 17, 2013, 38 TexReg 7111 |
